Management of patients with aneurysmal subarachnoid haemorrhage

Outcome of patients with aneurysmal subarachnoid haemorrhage (ASAH) has improved, but is still poor. After the introduction of endovascular treatment of intracranial aneurysms, much attention has been given to indications for and advances in endovascular and microneurosurgical techniques to occlude aneurysms, but management of patients with ASAH encompasses much more than occluding the aneurysm.

This review describes recent advances in diagnosis and general management of ASAH and in knowledge and medical treatment of delayed cerebral ischaemia and rebleeding.

In patients with a head computed tomography scan performed less than 6 h after headache onset and reported negative by a staff radiologist, lumbar puncture can be withheld. Patients with ASAH should preferably be treated in a tertiary care centre that treats more than 100 ASAH patients per year. Currently, the only treatment strategy to reduce the risk of delayed cerebral ischaemia remains nimodipine; there is no place for statins or magnesium sulphate, nor for lumbar drainage. Hypervolaemia and induced hypertension may be less beneficial than presumed, and further trials are urgently needed. Very early and short treatment with antifibrinolytic drugs may also be beneficial, but data from ongoing trials should be awaited before this treatment strategy can be implemented.